Neurology Flashcards

1
Q

What are the causes of Virtigo?

A
Benign paroxysmal positional vertigo.
Acute labyrinthitis 
Meniere's Disease
Ototoxicity
Acoustic Neuroma
Herpes Zoster
Traumatic damage
Stroke/TIA
Migraine
Alcohol intoxication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is BPPV? It’s cause and symptoms?

A

Condition that causes sudden onset of dizziness associated with head movement.

Causes - usually idiopathic. If young = trauma.

Symptoms - Episodic (10-20 secs) virtigo associated with change of head position. Can be associated with nausea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What features are not associated with BPPV?

A

Tinnitus

Hearing Loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Investigations for BPPV?

A

Family history of RA / back pain - may complicated further examinations
Ear examination
Dix-Hallpike test -

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Management of BPPV?

A

Watch and wait - is this acceptable for the patient?
Epley manoeuvre
Consider Brandt-Daroff exercises. (vestibular rehabilitation)

Betahistine is commonly used (histamine analogue) but not very effective.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is a Dix-Hallpike test and what is it used for?

A

Test for BPPV.
Patient sites up, turns head 45o in one direction. Lower patient in this position, make sure head is 30o below horizontal. Observe for rotatory nystagmus and vertigo.

Should be performed, tilting the head both left and right.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the Epley Manoeuvre and what is it used for?

A

Used for the management of BPPV.

With patient lying down, rotate head 90o. Ask patient to turn to that side whilst lying down. Turn head 90o so the head is facing the floor. Ask patient to sit up maintaining the direction of the head tilt. Realign head and flex neck downwards.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is meniere’s disease and what are the symptoms?

A

Disorder of the inner ear. Characterised by pressure and dilatation of the endolymphatic system.

Symptoms - recurrent episodes of vertigo (>20 mins each), tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
a sensation of aural fullness or pressure is now recognised as being common
nystagmus and a positive Romberg test

episodes last minutes to hours
typically symptoms are unilateral but bilateral symptoms may develop after a number of years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the classic triad of meniere’s disease?

A

Vertigo (recurrent)
Tinnitus
Fluctuating hear loss

Usually unilateral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Investigations for meniere’s disease?

A

ENT assessment to confirm diagnosis.
Refer to audiology
Admit if symptoms severe - IV labyrinthine sedatives (meclozine, promethazine) and fluids.
Second line - Diazepam or Prochlorperazine.

Betahistine for prevention.

Reassurance. Inform the DVLA.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is acute labyrinthitis and what are its symptoms?

A

Also known as vestibular neuonitis.

Vertigo following a viral infection.

Features - Abrupt onset of severe vertigo (recurrent, lasting hours), nausea and vomiting.
Horizonal nystagmus is common.
NO DEAFNESS OR TINNITUS.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the treatment of acute labyrinthitis?

A

Vestibular rehabilitation exercises for those with chronic symptoms.
Buccal or IM prochlorperazine for those with acute severe symptoms.
Less severe = proclorperazine or anti-histamines.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is acoustic neuroma and what are the symptoms?

A

Schwannoma from the vestibular nerve (rare tumour of the nervous system).
Growth rate = 1mm/year
Tumours slow growing and often benign

Symptoms - unilateral hearing loss with vertigo occurring later.
Progressive = cranial nerves affected 
-V (absent corneal reflex), VI, IX, X)
Raised ICP if advanced.
Bilateral = NF2
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Acoustic Neuroma treatment.

A

Refer urgently to ENT.

Surgery, radiotherapy or observation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Acoustic Neuroma Investigation

A
ENT referral (Urgent)
MRI of cerebellopontine angle is investigation of choice
Audiometry is important. (
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Syncope differentials

A
Reflex (vasovagal, situational, carotid sinus hypersensitivity, atypical)
Orthostatic hypotension 
Cardiac syncope (arrhythmia, structural heart disease)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Common examinations for syncope.

A

Cardiac examination
ECG (including 24h)
Blood pressures (standing up and lying down)
Table tilt test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is vasovagal syncope, signs, management?

A

Type of reflex syncope. Most common cause of fainting.

Caused by emotional distress (prolonged standing in heat). Common in young adults/adolescents.
Classic faint.

Benign - reassurance and trigger recognition. Avoid BP lowering agents.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Cardiac syncope. Causes, investigations, management.

A

Causes - arrhythmias, bradycardia. Can also be tachycardia.
Structural - Hypertrophy, valvular, MI
Others - pulmonary embolism.

Cardio examination
ECG
24 hr ECG
U&E's, FBC, Ca2+, glucose
Echo
CT/MRI brain
ABG (pulmonary embolism, low CO2 suggests hyperventilation)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

How do you classify epilepsy?

A

Either by seizure types of epilepsy syndrome.

Seizure types - Focal (starts in one place but can spread), generalised (both hemispheres affected).

Epilepsy syndrome - juvenille, Dravets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Focal seizure classifications.

A

Without impairment of consciousness or with.

Frontal movements - posturing (prolonged extension or flexion of the limbs) or peddling. Motor arrest subtle behavioural changes. Language can be affected as well.

Parietal - sensory disturbances such as tingling, numbness or pain
Can also have motor symptoms (if spread to the pre-central gyrus)

Temporal - automatisms (complex motor phenomena with unconsciousness - lip-smacking, chewing, swallowing)
Deja Vu
Emotional disturbance - tremor, panic anger
Hallucinations - smell, taste sound

Occipital - Visual disturbances (spots, lines, flashes)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

General seizure classifications

A

Tonic-clonic - loss of consciousness, limbs stiffen (tonic), then jerk (clonic)

Absence seizure - begin in childhood, sharp onset and offset, eyelid twitching.

Myoclonic - shock-like contraction of the limbs, without impairment.

Atonic - sudden loss of muscle tone causing falls.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Diagnosis of Epilepsy

A

All patients with a seizure must be referred to specialist.
Take a thorough examination and establish the type of seizure.

Rule out provoking causes - trauma, stroke, haemorrhage, raised ICP, alcohol or benzodiazepine withdrawal
Metabolic causes - hypoxia, hypernatraemia, hypocalcaemia, hyperglycaemia.
Infection - meningitis
Drugs - cocaine, tryclyclics.

Investigations - Bloods (see for above). ECG. Consider EEG
MRI - structual cause
Drug levels - anti-eplieptic medication

DVLA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Headache differentials

A
Tension headache
Glaucoma 
Migraine 
Trigeminal neuralgia
Cluster headache
Meningitis
Sinusitis
Head injury (extradural, subdural, subarachnoid)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Characteristics and management of a tension headache
"tight band across the forehead. Symptoms tend to be bilateral. Lower intensity than a migraine. Also no aura, N+V May be related to stress. Other triggers: Dehydration, alcohol, skipping meals Can coexist with a migraine. NICE - Acute = aspirin, paracetamol or NSAID as first-line. Prophylaxis - 10 sessions of acupuncture over 5-8 weeks Low-dose amitryptyline Above is for chronic tension-type (occuring 15 days or more per month)
26
Characteristic of a cluster headache (+risk factors)
Intense pain around the eye. Usual presentation is a headache and a red, watery eye with nasal congestion/rhinorrhoea Other symptoms - Lacrimation, eyelid oedema, facial/forehead sweating, miosis (constriction) and/or ptosis Frequency - 1 every other day - 8 times a day Clustered for 6-12 weeks followed by pain free periods Most commonly affects men in their 20s or older who are smokers, family history, male sex and smoking/alcohol are risk factors.
27
Management of a cluster headache
C - reassurance, lifestyle changes - alcohol and smoking avoidance (triggers) M - Acute Attacks - 100% oxygen (15 min via non-rebreather) - caution if COPD and subcut sumatriptan Prophylaxis - Verapamil or prednisolone S - Not much place but optical nerve stimulation may have a role in preventative medically-refractory chronic cluster headaches. (very last line management)
28
Differentials / investigations of a cluster headache
``` Migraine Paroxysmal hemicrania Trigeminal neuralgia Giant cell arteritis Headache associated with sexual activity Angle-closure glaucoma ``` Brain CT / MRI - rule out secondary causes (tumour, cavernous sinus pathology) (normal in cluster) ESR - Exclude giant cell arteritis if over 50. Pituitary function tests ?
29
Trigeminal Neuralgia Symptoms, investigations
Facial pain syndrome in the distribution of 1 or more divisions of the trigeminal nerve. Symptoms - paroxysms of intense, stabbing pain lasting seconds in the trigeminal nerve area (V2 and V3). Face screws with pain. Triggers - washing affected area, shaving, eating, talking Typically male >50. AGE AND MS are risk factors. Investigations - clinical diagnosis THINK SECONDARY CAUSES = intra-oral X-ray (if dental cause suspected - dental caries, fracture). MRI - tumour, infarct, MS plaque
30
Trigeminal Neuralgia management
Medical preferred: Anticonvulsants - Carbamazepine 1st line 2nd line - Topiramate 3rd line - gabapentin, lamotrigine Consider baclofen (anti-spasmodic if resistant to the above) For medically resistant - surgery = microvascular decompression (surgery to the compressive loop)
31
Migraine Presentation
Chronic, genetically determined, episodic neurological disorder that usually presents early-to-mid life. Risk factors - family history, childhood motion sickness, caffeine, high altitude, female sex, menstruation, divorced, widowed or separated. Stress, overuse of headache medication, lack of sleep. ``` Prolonged headache - unilateral often. Throbbing/pulsing. Aura (blurred visiob) Hemiplegic disabling Lasts 4-72 hours Photophobia N+V Associated with triggers - worse with activity, caffeine, sex, chocolate, dehydration ```
32
Investigations for a migraine
Clinical diagnosis ESR - rule out temporal arteritis (>50) LP - abnormal if caused by subarach, meningitis, MRI Brain (with contrast) - recommended for all concerning headaches. - may identify space occupying lesion or ischaemia CT without contrast - emergency evaluation of acute headache (evaluate for intracranial haemorrhage)
33
Acute Migraine Management
Mild-moderate = NSAIDs / paracetamol + anti-emetic (metoclopramide), hydration Severe = Triptan (almotriptan, sumatriptan). + same as above IF PREGNANT = PARACETAMOL, ANTI-EMETIC, HYDRATION, MAGNESIUM A+E severe = rescue therapy - metoclopramide or prochlorperazine + dipenhydramine or triptan + oxygen + IV corticosteroid
34
Ongoing Migraine Management
C - trigger avoidance and behavioural modification (relaxation/CBT), avoid caffeiene, cheese, chocolate etc. M - NON-PREGNANT - cycle control (hormonal therapy if menstrual associated). Magnesium, triptan (frovatriptan or zolmitriptan) ?? or is it topiramate Basically - propranolol, amitriptyline, or topiramate verapamil (for hemiplegic migraine)
35
Red Flags for Headaches
``` New onset in > 50 years old Immunocomprimised History of malignancy known to metastasis to the brain Vomiting Impairment of consciousness Thunderclap Focal neurological symptoms Change in characteristic Abnormal neurological examination Headache with changes in posture Jaw claudication Neck stiffness Fever Personality change ```
36
Head Injury Approach
``` PROTECT AIRWAY AND C-SPINE Oxygen if sats <92% Stop blood loss Treat seizures with phenytoin Assess consciousness - intubate if GCS < 8 Neuro examination History Check for CSF leak from nose/ear ```
37
What are the indications for CT Head Immediately following a Head Injury (<1 HR)?
``` GCS < 13 on assessment GCS < 15 after 2 hours Suspected open or depressed skull fracture Sign of basal skull fracture Post-traumatic seizure Focal neurological deficit >1 episode of vomiting ```
38
What are the indications for CT Head within 8 hours following a Head Injury?
Age > 65 History of bleeding or clotting disorder Dangerous mechanism of injury (pedestrian / cyclist hit by a car) >30 mins of retrograde amnesia immediately before head injury. Patient on warfarin.
39
Presentation of Extradural haemorrhage.
Typically trauma. Lucid interval. Typically - initial loss of consciousness, briefly regains and then loses again. Fixed, dilated pupil due to uncal herniation causing compression on third cranial nerve Signs of raised ICP. Headache. Confusion, seizures, UMN signs. Dilated pupil (ispilateral)
40
What is an extradural haemorrhage and how are they sustained?
Collection of blood between the skull and dura. Almost always caused by trauma (low-impact trauma). Usually in the temporal area (pterion overlies the middle meningeal artery which is therefore vulnerable).
41
Investigations for Extradural haemorrhage
``` ABCDE Bedside obs Assess GCS Bloods - coag CT HEAD Biconvex/lens shaped, hyperdense collection around the surface of the brain, limited by suture lines of the skull ```
42
Management of extradural haemorrhage
ABCDE Stablise - protect airway and C-spine Transfer to neurosurgery for clot evacuation / ligation of bleeding airway Mannitol to reduce ICP
43
What is a subdural haematoma, risk factors and how are they caused?
Collection of blood beneath the dural layer of the meninges. Risk factors: 3A's - Age, Alcohol and Anticoagulation (also coagulopathy) Cause: High impact trauma, can therefore be associated with underlying brain injury.
44
Presentation of a subdural haematoma
Ranges from incidental finding to coma and coning (due to herniation) Headache - gradually gets worse over hours-days N+V Diminished GCS Losing consciousness Seizures, sensory changes if getting worse Signs of raised ICP
45
Investigations for a subdural haematoma
ABCDE Basic obs / GCS Non-contrast CT (standard choice in suspected haematoma). - will see a crescent shape collection of blood (not limited by suture lines). May also be midline shift Consider MRI - assess extent of brain injury
46
Management of a subdural haematoma
ABCDE Incubate if GCS < 8 Analgesia (pain can increase ICP) Neurosurgical referral if persistent symptoms after initial assessment, focal neurological deficit or significant findings on CT. If small haematoma (<10mm) and midline shift <10mm then observation, monitoring and follow up. Prophylactic anti-emetics Correction of coagulopathy If large (>10 mm) or midline shift >5 mm then surgery - burr hole cranitomy. Chronic - antiepileptics, elective surgery and coagulopathy correction. Consider conservative - fall management, avoid activities that risk injury, controlled return to normal activities, having someone at home within first 24 hours to observe them.
47
What is stroke, the main types and the causes?
Stroke - rapid neurological deficit resulting from altered blood supply to the brain lasting > 24 hours Types - Ischaemic, haemorrhagic (+TIA) Ischaemic - 85% of strokes, emboli, typically arising from the heart (AF/MI/Valve disease), aortic arch, carotid artery (atheroma) Haemorrhagic - intraparenchymal, subarachnoid. Cause - Vascular abnormality (aneurism), coagulopathy, vasculitis
48
Signs / symptoms of stroke
``` FAST Focal neurological signs - weak, numb Hemiplegia Sudden onset - often from waking up Symptoms worsen within hours Problems with speech Balance problems Also signs of source of emboli (ischaemic stroke) - murmur, fever (infective endocarditis, valve disease) ```
49
3 things to lookout for to help classify strokes?
Unilateral hemiparesis and/or hemisensory loss of face, arm or leg (UMN signs) Visual signs - particularly homonymous hemianopia Higher cognitive dysfunction - dysphagia, aphasia
50
Total Anterior Circulation Stroke (TACS) cause and presentation
Cause - occlusion of the internal carotid, cerebral or anterior cerebral arteries Presentation - unilateral hemiparesis Homonymous hemianopia Higher cognitive dysfunction (dysphasia, aphasia)
51
Stroke investigations
Bloods - FBC, platelets, ESR, U+Es and LFTs, coag, glucose, cholesterol (know why we do these - notes) CV tests - ECG, CXR, Echo, carotid duplex US EMERGENCY NEUROIMAGING - CT (rules out haemorrhage and tumour but may be initially normal on an ischaemic stroke, also allows thrombolysis) CT angiography (large vessel occlusion) MRI - more sensitive than CT but less available
52
Stroke Management
ABCDE Prevent hypoxia, hypoglycaemia, hypotension and infection DVT prophylaxis if immobile Admit to specialist stroke ward MDT - physio, OT, speech and language therapy Ischaemic - Thrombolysis if 4.5 hours of onset of symptoms and patient has not had previous haemorrhage or pregnant or uncontrolled HTN Thrombectomy - if large vessel occlusion Antiplatelets - Aspirin 300 mg OD for 24 hours post thrombolysis. Continue for 2 weeks before switching to long-term antiplatelet. Haemorrhagic stroke - neurosurgical referral Secondary Prevention - Antiplatelet (clopidogrel 1st line followed by Aspirin + modified-release dipyridamole 2nd line). Anticoag instead for anti-platelet if AF Statins for all Screen and treat HTN Carotid endarterectomy or stentin if > 50% carotid stenosis Lifestyle changes
53
When can you give thrombolysis for a stroke?
Haemorrhagic stroke excluded. Patient presents within 4.5 hours on symptom onset No previous intracranial haemorrhage, uncontrolled HTN or pregnant Also no CI to thrombolysis Thrombolysis = Alteplase or Tenecteplase
54
Multiple Sclerosis Presentation
Optic Neuritis - ranges from reduced vision and colour blindness to complete vision loss. May see RAPD, disc swelling Transverse myelitis Other: - Dysaesthesia (feeling like water trickling or electric shock). Motor - spastic weakness, cerebellar symptoms, dysphagia, constipation, fatigue, cognitive impairment As MS becomes progressive - gradual accumulation of disability
55
Multiple Sclerosis Investigations
MRI brain and spinal cord - Plaques: Hyperintense lesions on T2-weighted MRI or enhancement of active lesions with gadolinium-enhanced T1 MRI. CSF - Oligoclonal IgG bands on electrophoresis which are not found in serum Also increased protein and WBC (but less common) McDonald Criteria Other: FBC, CRP - signs of inflammatory disease B12 - cause for neurological symptoms TSH - eye disease U+Es - for electrolyte neurological symptoms Glucose - for diabetes causing neuropathy and eye disease HIV - various neurological manifestations
56
What is the McDonald Criteria?
Used in MS for diagnosis >2 or equal to 2 attacks, disseminated in time (>30 days) and place (>2 areas of CNS), not explained by anything else Diagnosis can be purely clinical, provided there are objective neurological findings for at least 1 attack and attacks last >24 hours Radiological diagnosis requires 2 lesions
57
Describe the management of status epilepticus
ABCDE IV access - bloods = FBC, toxicology screen, LFTs, glucose, U+E, calcium Give IV glucose, thiamine or fluids as required Give IV lorazepam (or rectal if pre-hospital) - ideally in slow bolus (30s) Repeat after 10 mins if required Ongoing seizure (20 mins) - phenytoin loading dose Seizure ongoing (30 mins) - general anaesthesia with prenobarbital or propofol.
58
Presentation of Meningitis
``` Classic triad - fever, headache, neck stiffness Photophobia LOC Drowsiness N+V Could be associated with a recent URTI Rash (invasive meningococcal infection) Seizures ```
59
Meningitis CSF Profile: ``` Yellow Polymorphonuclear cells - slightly increased Lymphocytes - markedly increased Protein - increased Glucose - decreased ``` Infection?
Tuberculosis (bacterial = polymorphonuclear cells would be markedly increased Viral = clear fluid, normal glucose (or slightly decreased). Normal protein
60
What is syringomyelia and how does it present?
Development of fluid-filled cyst (syrinx) within the spinal cord. Typically develop due to blocked CSF flow (commonly associated with a Chiari malformation) Presentation - mean age of diagnosis = 30 years Dissociated sensory loss - absent pain and temperature sensation with preserved light touch, vibration and joint position sense. Distribution depends on position of the Syrinx (affecting a certain root distribution) Typical cervical syrinx - sensory loss over trunk and arms Also - wasting of the hands, claw hand Can also have Horner's syndrome (bilateral) UMN leg signs.
61
First line drug for focal seizures
Carbamazepine
62
Management of status epilepticus
ABCDE IV access- bloods - glucose, calcium u/es, LFT, FBC, First line drugs are benzodiazepines - diazepam (pre hospital rectally) - lorazepam 4mg repeated after 10 minutes if the seizure continues 20 mins - phenytoin 30 mins - general anaesthesia (propofol)
63
Presentation of hydrocephalus
``` Raised ICP Headache N+v Visual problems Normal pressure - urinary incontinence, dementia and gait disturbance ```
64
Classification of hydrocephalus
Communicating - impaired absorption of CSF, no obstruction (SAH, meningitis) Non-communicating - OBSTRUCTIVE - congenital abnormalities (arnold-Chiari) - bleeding, tumour Normal pressure - dilated cerebral ventricles
65
Presentation of intracranial venous thrombosis
Most commonly occur in sagittal sinus thrombosis | - headache, vomiting, seizures, decreased vision, papilloedema
66
Causes of venous sinus thrombosis
Numerous - anything that puts someone in a hypercoagulable state Common- pregnancy, COCP, head injury Dehydration
67
Investigations of dural sinus thrombosis
Exclude SAH and meningitis Thrombophilia screen Imaging - CT/MRI venography LP - raised opening pressure, may show RBCs or be normal
68
Management of dural sinus thrombosis
Anticoagulation with heparin or LMWH Still deterioration - endovascular thrombolysis or mechanical theombectomy Raised ICP - decompressive hemicraniectomy
69
Features of motor neuron disease
Think of in >40 years old with stumbling spastic gait, foot drop, proximal myopathy Mixed UMN and LMN signs Speech and swallowing affected? Bulbar palsy Does not cause sensory loss or sphincter disturbance Wasting of small muscles of hands is common Also frontotemporal dementia occurs
70
Degenerative cervical myopathy presentation
Caused by pressure in the neck Early symptoms are subtle then progress Pain in neck, upper and low limbs Loss of motor function - digit dexterity, doing up shirt etc. Loss of sensory function - numbness Loss of autonomic function- urinary/faecal incontinence Hoffmans sign - flicking one finger causes reflex twitching in the opposite
71
Management of degenerative cervical myelopathy
Specialist spinal services Early treatment needed Decompressive surgery
72
Classic triad of parkinsons
Resting tremor Rigidity Bradykinesia
73
Classic triad of parkinsons
Resting tremor Rigidity Bradykinesia
74
Do tremors improve or get worse with movement?
Improves Tremors more pronounced while resting or distracted (ask them to do a task with other arm)
75
Features of parkinsons
``` Bradykinesia Tremor at rest Shuffling gait Rigidity Flexed posture Depression Sleep disturbance Loss of snell ```
76
Carbidopa and benserazide are examples of what drugs
Decarboxylase inhibitors - given in parkinsons to prevent dopamine being broken down. Given with levodopa
77
First line management in parkinsons
Levodopa and dopa decarboxylase inhibitors
78
Symptoms of multiple system atrophy
Parkinsons Autonomic dysfunction - postural hypotension - constipation - urinary symptoms - sweating - sexual dysfunction - ataxia
79
What time frame should thromectomy be offered
Within 6 hours | Not used after 24 hours
80
Secondary prevention of stroke
Antiplatelet - 75mg clopidogrel If not acceptable or CI - aspirin plus modified-release dipyridamole
81
Presentation of gullian-barre syndrome
Features of infection 2-4 weeks prior - symmetrical ascending weakness - reduced reflexes - peripheral loss of sensation and neuropathic pain - cranial involvement - diplopia, bilateral facial nerve palsy - autonomic - urinary retention - LMN signs
82
Diagnosis of gullian-barre syndrome
Usually made clinically Brighton criteria Nerve conduction studies - reduced signal Lumbar puncture for CSF - raised protein with a normal cell count
83
Management of gullian-barre syndrome
``` IV immunoglobulin Plasma exchange Supportive care VTE prophylaxis - PE biggest killer Respiratory failure - intubation and ventilation ```
84
When should prophylaxis for migraine be given, drugs used?
2 or more attacks per month Topiramate or propranolol Not topiramate in child bearing age in women ``` If these fail - acupuncture Also riboflavin (B2) ``` Predictable menstrual migraine - frovatriptan or zolmatriptan
85
First line radiographic investigation in stroke
CT head | - rules out haemorrhagic
86
Contents of the cavernous sinus
Lateral wall components - oculomotor nerve - trochlear nerve - opthalmic nerve - maxillary nerve Contents of the sinus - internal carotid artery - Abducens nerve
87
Presentation of cavernous sinus syndrome
``` Opthalmoplegia (CN III, IV, VI) Autonomic dysfunction (horners) Sensory loss (trigeminal neuralgia) ``` Different from posterior communicating artery aneurysm - ptosis and dilated pupil Cavernous sinus - absent corneal reflex and proptosis
88
Managemeng of epilepsy
Most forms - sodium valproate Focal - carbamazepine Generalised 2nd line - lamotrigine Absence - sodium valproate, ethosuximide Myoclonic - 2nd line - clozipine, lamotrigine Focal - 2nd line - levetiracetam
89
Risk factors for IIH
Female sex Obesity Sleep apnoea Drugs - COCP, steroids, vitamin A, lithium
90
Presentation of IIH
``` Headache Blurred vision Papilloedema Photophobia 6th nerve palsy Visual field loss ```
91
Management of IIH
First line - weight reduction - eliminate causes - TCAs, retinoids, vitamin A - low sodium diet Medical - diuretics- acetazolamide, furesomide - topiramate - repeated lumbar puncture Surgical - CSF shunting
92
What is neurofibromatosis
Condition where tumours grow on nervous tissue | They can develop anywhere in the NS (brain, spinal cord and nerves)
93
Neurofibromatosis 1 vs 2
1 - cafe su last spots at least 6 Axillary and groin freckles Iris haematomas 2 - bilateral vestibular schwannomas - fewer cafe au last spots - tinnitus, vertigo
94
Path of the facial nerve
Exits brainstem at the cerebellopontine angle Passes through temporal bone and parotid gland Divides into 5 branches - temporal - zygomatic - buccal - mandibular - cervical
95
What is the function of the facial nerve
Motor - muscles of facial expression, strapedius of the inner ear Sensory - carries taste from anterior 2/3 of tongue Parasympathetic - supply submandibular and sublingual salivary glands and lacrimal gland
96
Differentiating between upper and lower motor neuron facial nerve palsy
Each side of forehead has UMN innervation from both sides of the face Each side of forehead has LMN from only one side of the brain UMN - forehead will be spared (as it has dual supply)
97
Management of bells palsy
Prednisone (within 72 hours) Lubricating eye drops Not resolved within 3 weeks - ENT referral urgently
98
What is ramsay hunt syndrome
Facial nerve palsy caused by VZV - look for rash over ear, pinna, inner ear - tender painful rash Treatment - prednisolone and acyclovir, also eye drops
99
Median nerve damage signs
Carpal tunnel | Sensory loss over first 3 and a half fingers and palm
100
Ulnar nerve damage signs
``` Elbow trauma Weakness / wasting of medial wrist flexor Interossei - cannot cross the fingers Claw hand Hypothenar wasting Sensory loss over ulnar fingers ```
101
Radial nerve damage findings
Compression at humerus Wrist drop Sensory loss variable
102
Sign of T1 root damage
Weakness in finger abduction
103
How long off driving if TIA or stroke if no neurological deficit
1 month
104
Epilepsy driving rules
Unprovoked/first seizure - 6 months off if no structural abnormalities or anything on EEG If so, then 12 months Drivers licence if 5 years no seizure in diagnosed epilepsy
105
What is cushings triad?
Widening pulse pressure Bradycardia Irregular breathing
106
Who is at risk of chronic subdural haematomas? Presentation
Alcoholics Elderly Several week fo months progressive history of either confusion, reduced consciousness or neurological deficit Can be incidental finding
107
Management of TIA
300 mg aspirin for 2 weeks 75 mg clopidogrel long term Secondary prevention- anti-hypertensive, diabetic modification, lipid modification AF - anti coagulation CAD - carotid endartectomy
108
T1 vs T2 MRI differences
T1 - fat is bright | T2 - fat and water is bright
109
Ptosis, down and out eye and dilated fixed pupil. What cranial nerve damage?
Oculomotor (CN III)
110
Defective downward gaze (vertices diplopia). Cranial nerve palsy? And its function
IV torchlear - eye movement
111
``` No corneal reflex Loss of facial sensation Sharp pain along face Paralysis of mastication muscles Deviation of jaw ``` What nerve palsy? Function?
V trigeminal Facial sensation Mastication
112
Defective eye abduction and horizontal diplopia, eye pulled inward which cranial nerve palsy? Functuon?
Abducens (VI) Eye movement (lateral rectus)
113
IX nerve name and function
Glossopharyngeal Taste (posterior 1/3 Rd of tongue) Salivation Swallowing
114
Weakness turning head in one direction, cranial neve palsy?
XI (accessory) on contralateral side
115
XII nerve name, function and what palsy may look like
Hypoglossal Tongue deviated towards side of lesion
116
Uvula deviation, loss of gag reflex, difficulty swallowing which nerve palsy?
Vagus (X) Uvula deviates away from site of lesion
117
Which cranial nerve cause uvula deviation?
Vagus (X) - deviates away from lesion
118
What cranial nerve palsy causes tongue deviation?
Hypoglossal (XII) | Deviates towarsds the lesion
119
Classical history of vestibular schwannoma
Combination of virtigo, hearing loss, tinnitus and absent corneal reflex (cranial nerve V) Cranial nerve VIII - vertigo, unilateral sensineural hearing loss
120
What does C8 radiculopathy look like?
C8 dermatome lack of sensation - medial aspect of hand (little finger) Weakness of flexion of distal interpahalgeal and metarcarpophalangeal joints)
121
Which is the only cervical nerve root that comes out below the vertebra?
C8
122
Features of Wernickes encephalopathy
Usually in alcoholics Lack of B1 Confusion Opthalmopegia/nystagmus Ataxia
123
Classical symptoms of normal pressure hydrocephalus
Urinary incontinence Dementia Gait abnormality similar to parkinsons
124
Charcot Marie tooth disease features
Symptoms usually occur before aged 10 but onset of symptoms can be delayed until in 40s Affects peripheral motor and sensory neurons ``` High foot arches (pes cavus) Distal muscle wasting Weakness in lowe legs - weak ankle dorsiflexion Reduced tendin reflexes Reduced muscle tone Perioheral sensory loss ```
125
Duchenne muscular dystrophy presentation
Progressive degeneration and weakness in specific muscle groups Most patients lose ability to walk by aged 12 Most need resp support by 25 SENSATION INTACT
126
What is spared in MND?
Eye movements
127
What is progressive muscular atrophy?
Type of MND LMN signs only Affects distal muscles before proximal Carries best prognosis
128
Fasiculations should make you think of what?
MND
129
Innervation of the eye muscles
All rectus apart from lateral and inferior oblique = oculomotor Superior oblique = trochlear Lateral lectures = VI abducens
130
Signs of cerebellar syndrome
DANISH ``` Dysdiadochokinesia Ataxia Nystagmus (horixontal) Intention tremor Staccato slurred speech Hypotonia ```
131
What is anterior inferior cerebellar syndrome?
Stroke of that artery Ipsilateral loss of facial pain and temperature Contralateral limb/torso pain and temperature loss Ataxia nystagmus
132
What is webers syndrome?
Beaches of the posterior cerebral artery stroke Ipsilateral CN III palsy Contralateral weakness of upper and lower extremity
133
Further tests for someone less than 55 years old, presenting with stroke?"
Autoimmune and thrombophikia screening
134
Management of stroke associated with AF
2 weeks of aspirin | Switch to oral anticoagulation
135
If s stroke affects upper limbs more than lower limbs is it anterior or middle cerebral artery?
Middle
136
Anterior cerebral artery stroke presentation
Contralateral hemiparesjs and sensory loss affecting the lower limbs more than upper No facial weakness or speech impairment
137
What measurement should be used to assess someone's ability to return to daily activities after a stroke?
Barthel index